Transcript Ovarian Tumours

Ovarian Tumours
Max Brinsmead MBBS PhD
November 2014
Incidence
1:10 women will undergo surgery during a
lifetime because of suspected ovarian
mass
10% turn out to be non ovarian
The vast majority in pre menopausal
women are benign
Ovarian tumours present as:
Pain
Mass
An incidental finding
But the most important thing to determine is whether:
It is functional or neoplastic?
Benign or malignant?
After the identification of a pelvic adnexal mass
evaluation is usually by ultrasound but think…
Is there a short history of symptoms?
Is this a woman of reproductive age?
Cycling spontaneously?
Or using progestin-only contraception?
A past history of “cysts”
Pregnant?
Had IVF?
Pathology of Functional Ovarian Tumours:
A 2 cm “cyst” occurs every month = mature follicle
Haemorrhage from or into a corpus luteum is common
Failed follicular rupture can also result in a cyst
Endometrioma = ovarian endometriosis
Ultrasound features of a Functional Ovarian Tumour
Thin walled
Usually no solid components
Usually no septa or thin walled septa
Usually <6 cm size
Usually avascular to colour Doppler
Change rapidly
And disappear within 6-8w
• (A role for COC during this period not supported by Cochrane)
Management Guidelines for a Simple Cyst in a
Premenopausal Woman
Ignore if <30 mm size and asymptomatic
Repeat scan after 3m for simple cysts 30 – 50 mm
– Further Ix or laparoscopy if they increase in size
– Repeat scan in 12m if unchanged and < 70 mm
Further Ix and or laparoscopy for cysts >70 mm
– Ca 125
– Further imaging (CT or NMR)
Laparotomy may be better for suspected dermoid
>70 mm
Clinical Features of a Neoplastic Ovarian Tumour:
Older women
Larger tumours
Solid/Cystic or multiple septate
Bilateral
Fixed, tender or craggy to palpation
Ascites present
Vascular to colour Doppler
Persist or enlarge (4m re evaluation for
postmenopausal women)
Associated with positive tumour markers – CA125,
CA19.9, CEA (AFP, HCG, LDH)
Differential diagnosis for an Ovarian Tumour:
Full bladder
Pregnancy
Loaded caecum or sigmoid colon
Hydrosalpinx
Mesenteric cyst
Fiboid (subserosal)
Pelvic kidney etc
Paraovarian cyst
Comprehensive DD of Adnexal
Masses
Pathology of Ovarian Neoplasms
Germ cell Tumours
– Benign cystic = Dermoid (the most common neoplasm of young ♀ –
15% bilateral)
– Malignant includes Dysgerminoma (LDH), Teratocarcinoma,
Endodermal sinus Ca (AFP), Chorioca (bHCG)
Epithelial
– Cystadenoma (serous and mucinous)
– Cystadenocarcinoma Serous
–
Mucinous
–
Endometroid
–
Clear cell adenoCa
Functional
– E2 producing (granulosa cell benign or malignant)
– Androgen producing (Androblastoma)
Secondary Cancers (Stomach, Bowel, Breast etc)
Role of Ca 125
Of most value in the evaluation of adnexal mass
in postmenopusal women
Too many false positives in premenopausal
women
– Endometriosis, Adenomyosis, Fibroids & PID
Always of concern if >200
Specific only for epithelial tumours
– And only 50% sensitive for early stage disease
Staging of Ovarian Cancer:
Stage 1A - Confined to one ovary
1B - Ascites or +ve peritoneal cytology
Stage 2A - Involves uterus or tubes
2B - Involves other pelvic viscera
Stage 3A - Confined to pelvis
3B - to lymph nodes or upper abdominal implants >2cm
Stage 4 - Distant metastases
Treatment of Ovarian Cancer:
Debulking surgery = TAH + BSO+Omentectomy
Chemotherapy
Radiotherapy
Special cases
• Children
• Young woman – no children
• Advanced disease
Prognosis for ovarian cancer:
Overall 30 – 35% but this is because it presents
late
With modern gynaecological oncology
(debaulking + aggressive combination
chemotherapy) it should be >50%
Preventing ovarian cancer:
Screening
- Vaginal exams
- Ultrasound & CA125
Have been disappointing – too many false positives
Prophylactic Oophorectomy
- at hysterectomy (40%)
- for genetically predisposed
(BRAC carriers)
Prophylactic salpingectomy
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